269. A Review of Gram Negative Endogenous Endophthalmitis at University Hospital in Newark

Abstract Background Endophthalmitis (EO) is an ocular emergency characterized by intraocular inflammation, usually in response to infection. While most cases are exogenous, gram negative (GN) EO account for 10-24% of all cases, and endogenous EO (EEO) account for 2-8% of all cases. Risk factors for EEO include diabetes mellitus (DM), IV drug use, and indwelling catheters. Major sources of infection are urinary tract infections (UTI), liver abscesses, pneumonia, and bacteremia. Common pathogens include K. pneumoniae, P. aeruginosa, and H. influenzae. Outcomes are poor, with only 20% of patients achieving improved visual acuity, and 30-40% requiring enucleation. Methods Retrospective analysis was performed on patients diagnosed with EO (n=89) at University Hospital in Newark from January 2016 to December 2020 using ICD-10 codes H44.0-H44.009, H44.1, and H44.19. Patients included were 18 years of age or older with culture proven GN endogenous EO (GNEEO) (n=7). Outcomes included anatomical success, functional success, and mortality at 28 days and 3 months. Results 7 of 89 patients met criteria for GNEEO (median age 67, 4 males, 71.4% Hispanic/Latino). Comorbidities included hepatobiliary disease (57.1%) and DM (42.9%). All 7 patients presented with ocular symptoms and 3 had non-ocular symptoms. Primary sources of infection included UTI, prostate abscess, and pneumonia/empyema. Eye cultures identified Pseudomonas in 4 patients and Klebsiella in 3 patients. Mean antibiotic length was 17.7 days with 6 patients receiving intravitreal antibiotics. Enucleation was performed in 3 patients. 2 patients had functional success and 4 had anatomical success, with 0 mortality at 28 days and 3 months. Table 1. Ocular symptoms on presentation of cases of gram negative endogenous endophthalmitis Table 2. Positives cultures obtained from cases of gram negative endogenous endophthalmitis Conclusion Although rare, GNEEO causes significant morbidity, with only 2 recovering visual acuity and 3 requiring enucleation. Risk factors, sources of infection, and microbes were all consistent with those in previous reports. Hepatobiliary disease and DM were the most prominent risk factors while sources of infection included UTI and empyema. Eye cultures were positive for K. pneumoniae and P. aeruginosa, two common pathogens previously identified. This case series highlights the importance of prompt recognition and initial treatment of GNEEO with empiric coverage that includes vancomycin and ceftazidime. Disclosures All Authors: No reported disclosures


Session: P-13. CNS Infection
Background. Endophthalmitis (EO) is an ocular emergency characterized by intraocular inflammation, usually in response to infection. While most cases are exogenous, gram negative (GN) EO account for 10-24% of all cases, and endogenous EO (EEO) account for 2-8% of all cases. Risk factors for EEO include diabetes mellitus (DM), IV drug use, and indwelling catheters. Major sources of infection are urinary tract infections (UTI), liver abscesses, pneumonia, and bacteremia. Common pathogens include K. pneumoniae, P. aeruginosa, and H. influenzae. Outcomes are poor, with only 20% of patients achieving improved visual acuity, and 30-40% requiring enucleation.
Methods. Retrospective analysis was performed on patients diagnosed with EO (n=89) at University Hospital in Newark from January 2016 to December 2020 using ICD-10 codes H44.0-H44.009, H44.1, and H44.19. Patients included were 18 years of age or older with culture proven GN endogenous EO (GNEEO) (n=7). Outcomes included anatomical success, functional success, and mortality at 28 days and 3 months.
Results. 7 of 89 patients met criteria for GNEEO (median age 67, 4 males, 71.4% Hispanic/Latino). Comorbidities included hepatobiliary disease (57.1%) and DM (42.9%). All 7 patients presented with ocular symptoms and 3 had non-ocular symptoms. Primary sources of infection included UTI, prostate abscess, and pneumonia/empyema. Eye cultures identified Pseudomonas in 4 patients and Klebsiella in 3 patients. Mean antibiotic length was 17.7 days with 6 patients receiving intravitreal antibiotics. Enucleation was performed in 3 patients. 2 patients had functional success and 4 had anatomical success, with 0 mortality at 28 days and 3 months. Conclusion. Although rare, GNEEO causes significant morbidity, with only 2 recovering visual acuity and 3 requiring enucleation. Risk factors, sources of infection, and microbes were all consistent with those in previous reports. Hepatobiliary disease and DM were the most prominent risk factors while sources of infection included UTI and empyema. Eye cultures were positive for K. pneumoniae and P. aeruginosa, two common pathogens previously identified. This case series highlights the importance of prompt recognition and initial treatment of GNEEO with empiric coverage that includes vancomycin and ceftazidime.
Disclosures. Background. The term "neurosyphilis" refers to infection of the central nervous system (CNS) by Treponema pallidum. It can occur at any time after initial infection. Early in the course of syphilis, the most common forms of neurosyphilis involve the cerebrospinal fluid (CSF), meninges, and vasculature (asymptomatic meningitis, symptomatic meningitis, and meningovascular disease). Late in disease, the most common forms involve the brain and spinal cord parenchyma (general paralysis of the insane and tabes dorsalis).

Methods.
A 31-year-old man who suddenly developed a new onset generalized tonic clonic seizure, was admitted to the emergency department. He had no history of epilepsy and denied any vision or gait problems. The brain MRI showed no abnormalities. He had a history of rapid plasma reagent (RPR) titer 1:32 and a positive fluorescent treponemal antibody absorption (FTA-ABS) test in 2017. However, the RPR result was non-reactive when he retested a week later and therefore was not diagnosed with syphilis and did not get treated at that time. His most recent RPR titer was 1:16. HIV serology and other STD tests were all negative. His wife and his 3 kids were negative for syphilis. Due to serological evidence of syphilis and neurological symptoms, we arranged him to get a lumbar puncture to rule out neurosyphilis.
Results. His CSF study showed positive venereal disease research laboratory (VDRL), WBC cell count 44 cells/ul (lymphocytes 80%, Neutrophil 20%), Glucose 50 mg/ dl, Protein 75 mg/dl. Based on the CSF study, he was diagnosed with neurosyphilis and was treated with intravenous Penicillin G 3-4 million units every 4 hours for 14 days, followed by Benzathine Penicillin 2.4million units intramuscularly on day 21.
Conclusion. This is an unusual case because his false negative RPR result has hindered the prompt diagnosis and management of syphilis. RPR is a nontreponemal test and therefore it is not always reliable as a diagnostic criteria. False negatives in RPR may occur in certain conditions such as in early primary or in late stage syphilis and prozone phenomenon. This case illustrates the importance of using a reverse sequence algorithm in diagnosing syphilis. Thorough history taking is also crucial in conjunction with serological tests to determine the diagnosis and to ensure appropriate treatment.